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Case discussion

(Dr. Noridah Nordin)


13/6/11 10.27pm at emergency department Hospital Sungai Buloh 45 Indonesian Male no medical illness before High grade fever 3 days a/w chills and rigors headache, arhtralgia, myalgia, lethargy and malaise abd pain at epigastric area vomiting 2/7 20x per day diarrhoea 1/7 6x watery stools

LL swelling progressively worsening with rashes over the shins In Malaysia for 6 years Had recently gone home Indonesia for 3 months and came back to Malaysia 3 weeks ago Currently staying in Sungai Sirih Works in agriculture farm vegetable farm in Kuang for 3 weeks No river swimming, jungle tracking

BP 92/60 HR 112/min, moderate volume, regular rhythm SPO2 100% on NP 3L/min O2 RR 24/min Temp 37.9 Abd: No tenderness, liver palpable 3FB, Traube's space resonant RS: Decreased breath sounds over both LZ CVS: DRNM

pH 7.381 HCO3 20.7 BE -4.0 Glu 6.4 Lac 3.2

FBC: WBC 7.5 Hb 10.9 HCT 32 PLT 13

a) Dengue fever decompensated shock b) Severe malaria c) Leptospirosis d) Malaria e) Gram negative sepsis F) typhoid

What empirical antibiotic would you start after blood culture? a) IV C penicillin b) IV Rocephine/3rd gen cephalosporin c) IV Rocephine/3rd gen cephalosporin + azithromycin d) IV rocephine/3rd gen cephalosporin+ doxycycline e) no antibiotic

14/6/2011 at 4.30am ED Rx as gram negative sepsis TRO leptospirosis SPO2 on NP3L/min 100% BP 114/70 --> total 3.5L of fluids given; currently on 5mL/kg/hr --> 350mL/hr and IVI Noradrenaline 0.1mcg/kg/min ABG on NP 3L/min O2

pH 7.340 pCO2 30.1 pO2 94.5 HCO3 17.6 BE -8.8 Glu 5.0 Lac 2.9 sO2 97.4 BFMP: no malarial parasites seen

Is referral to intensive care necessary now? a) yes b) no

14/6/11 11.16am anaesth review in medical ward GCS full tachypnoeic, RR 40 on HFM 15 L/min

jaundice, petechia rashes , oedema bilateral limbs up to thigh periheries warm pulse bounding BP 87/50 on norad 31ml/H & dobutamine 4.1 ml/H PR 115 Lungs crepts Lt LZ & reduce a/e bibasal abd soft, tenderness over RHC region, liver palpable Patient intubated due to impending respiratory arrest and septicaemic shock

Diagnosis of CXR? a) ARDS b) Pulmonary haemorrhage c) cardiac failure d) severe pneumonia

14/6/11 1pm at ICU

BP 91/47 map 61 on iv noradrenalin DS 20mls iv dobutamine 4mls/h hr 116 spo2 97% on simv fio2 1.0 peep 12

Hb 8 TW 11 plt 10
Urea 14.2 mmol/L Sodium 127 mmol/L Potassium 4.00 mmol/L Creatinine 268.6 umol/L Bilirubin Total 117.3 umol/L ALT 75 U/L ALP 191 U/L INR 1.03 CK 4947 Amylase 1044 CRP 92

Would you escalate the antibiotic? a) yes b) no

iv hydrocortisone 100mg stat and 50 mg 6 hourly iv ceftriaxone 2 g od iv azithromycin 500 mg od iv doxycycline 100mg od vasopressin Packed cell transfusion 15/6/11 Leptospira IgM taken on 13/6/11 positive 15-16/6/11 CRRT

21/6/11 Day 8 ICU patient extubated 22/6/11 Transferred from ICU to general ward 27/6/11 Discharged home 21/6/11 Amylase 283 CK 356 27/6/11 TW 7.8 Hb 9.8 Plt 556 Creat 57 Bil 36